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The Medical and Surgical Treatment of Chronic. Rhinitis R. Moulton-Barrett, MD
Definationof Chronic Rhinitis symptoms of : • • nasal congestion rhinorrhoea anosmia sneezing or itchy nose lasting > 3 months in one year 40 million people in USA 50% seek medical advise 50% allergic in origin 6 million dollars spent on decongestants / yr.
Physiology of Nasal Congestion 3 portions: Flow: vestibule respiratory ( 92 % by area: 120 sq cm's) and olfactory Inspiratory- laminar, above inferior turbinate Expiratory - circum-laminar to paranasal sinuses Vestibule: 1/3 nasal resistance ( by acoustic rhinometryand MRI ) Nasal Valve: 2/3's total nasal resistance 0. 72 cm 2 ) ( the most narrow portion of the nasal cavity
Anatomy of the Inferior Turbinate Nerve: Post-ganglionic pterygopalatine ganglion fibres Inf Post Lat branch of Greater Palatine Nerve Artery: Single branch ofsphenopalatineartery enters 1 -1. 5 cm's from posterior superior bone travels anteriorlyalong superiorperiosteum Swelling: 40% of blood: through spongy submucosal venous tissue containing small vessels with leaky basement membranes 60% of the blood passes through a/v shunts: Sympathetic dependent reduces can overdrive by parasympathetics engorges + not histamine sensitive
Measurement of Nasal Resistance Acoustic. Rhinometry • assesses cross-sectional area andgeometry • (experimental) Hilberg 1989 Posterior. Rhinometry • Resistance = Pressure/Flow: disputed in terms of value Myrind N, 1980. Measurement of nasal airway resistance -is it only for article writers. Clinical. Otolaryngol 5: 161 -163.
Dynamic variation in nasal resistance Site: anterior-superior leading edge Hydrostaticpresssure: positional Nervous innervation: nasal cycle ( sympathetic tone ) Inflammatory process: chronic rhinitis Drug manipulation: vasoconstriction: 35% < resistance Inflam mediators: . histamine independent peptide and prostaglandin dependent
Physiology of Rhinorrhoea Serous & Mucoserous Glands parasympathetic and histaminedependent induce withmethacholine 'challenge' test 50 -100 cilia/cell beats mucus posteriorlyat 0. 3 -1 cm/minute a drop of saccarin taste in 20 minutes, : if delayed: perform microscopy rule out immotile cilia
Sneezing and Itching Histamine related: released by mastcells eosinophils & most importantly basophil cells Success of therapy: antihistamine/romoglycate c : proportional to histamine in nasal smears > mast, eosinophil basophil cells, , in vitro histamine release in response to allergens
Nasal Cytometry Purpose: Collection: Stains: Analysis: 1. determine likelihood medical treatment success 2. make diagnosis plastic bag and swab to slide Hansel's or Wright's > 5 neutrophils /high power field: 84% sensitive for sinusitis >25% eosinophil 100 cells: 70% diagnostic / allergicrhinitis(AR) The other 30%: eosinophilicnon- allergicrhinitis( NARE) Check H & P& Labs: h/o asthma FH AR (24%) Ig. E>50 U/ml ( usually >700 u/ml=AR), skin or nasal allergen challenge testing • If NARE: 93% respond to intra-nasal steroid therapy 66% if AR. vs. • If non-NARE/AR ( vasomotor: )< 19% respond to intra-nasal steroid therapy Mullarkey. M, Hill J and Webb R, 1980. J Allergy Clin Immunol 65(2), 122 -126
Causes of Rhinitis Allergic: 50 % Non-allergic. Eosinophilic: 35 % Vasomotor: 12 % Others : infective autoimmune atrophic <3% If only nasal obstruction must r/o masses
Allergic Nasal Challenge Test • Primary phase: 5 -30 seconds later sneezing occurs histamine dependent secondary tobasophil degranulation then delayed intra-nasal eosinophilia • Secondary phase: 7 hours later also caused bybasophil degranulation and parasympathetic overdrive histamine independent • If the allergen is rechallengedthere may be 100 x's greater response
Seasonal primary and secondary phases • when pollen counts are >50/cubic meter April-May: oak May-August: birch April-August: ragweed • or when in-home dust countsare elevated: Dermatophygoides pteronyssinus farinae : fans or mattress covers wash carpets open windows dusting humidifiers
Vasomotor. Rhinitis Secondary to: parasympathetic excess or sympathetic reduction • Drugs – rhinitis medicamentosa - topical cocaine and oxymetolazone produces prolonged vasoconstriction followed by reactive hyperemia via down regulation: alpha 1 & 2 blockage – antihypertensive medications vasodilatorsie. alpha blockers : • Hormonal – – estrogenic - BCP &Gravidarum estrogenic cholinesterase inhibition : acromegaly hypothyroidism responds tothyroxineand : old man's drip responds to testosterone :
Medical Therapy Intra-Nasal Steroids • Most useful agent: 60 -75% benefit all causes chronic rhinitis placebo 20% benefit • Inhibits: mast cell migration into nasal mucosa basophil cell, noteosinophilcell degranulation • least effect on: parasympathetic tone non-histamine related rhinorrhoeaof VR • S/E: freon causes drying crusting and bleeding ( 5% ) aqueous propylene glycol produce burning ( 5% ) very rare side - effects of septal perforation - blindness • Little benefit for VMR • positioning the patient
Medical therapy Anti-histamines • Have little effect on nasal blockage since histamine independent • Inhibit primary phase reactive symptoms • As effective as steroids for seasonal AR for sneezing & rhinorrhoea
Cromoglycate • Inhibition of protein kinase C leads to reduced degranulation • Has no place in the treatment of NARE or vasomotor rhinitis • Limits phase 1 symptoms and poor for congestion • Use 4 -6 times daily • Though newest drug'Nedocromil may reduce nasal obstruction in " allergicrhinitis
Ipratropiumbromide • Few side-effects since not absorbed by mucosa • Inhibits c-GMP synthesis which causes decreased glandular secretion • 400 ug QID may produce cracking and bleeding • 80 ug QID is equally effective in reducing rhinorrheabut not sneezing or obstruction •
Immunotherapy • Mechanism: cytokinerelated inhibition of basophil sensitivity via T cells rather than blocking antibodies Ig. G • " May be initiated at any time " during medical therapy for AR Gordon, 1992. O-HNS 107; 6(2), 861 pg. • Degree of success is multi-factorial and of particular importance is allergen avoidance therapy • 90% of asthmatics with positive skin and nasal challenge tests benefited by mold immunotherpy( Goode states: 75%) • Yet intra-nasal steroids are better tolerated and more effective in therapy for seasonal AR
Surgical Treatment: General principles • Rhinorrhoea neurectomyor steroid injection : • Obstruction all forms of therapy with good results : • Inferior turbinatecommonest cause of nasal obstruction : • Reduce the inferior turbinate during septoplasty • Atrophicrhinitisfrom turbinectomy extremely rare is
Choices: Inferior Turbinate steroid injection sclerotherpy outfracture submucous resection of bone submucosal bipolar electro cautery mucosa/ soft tissue resection. Ag. NO 3 : CO 2 laser or needle cautery turbinectomy partial or complete : neurectomy : pterygopalatine ganglion orvidian nerve by: cryo or sclero -therapy cautery or knife endo or non-endoscopically
Outfracture method: clamp and rotate outwards advantage: little bleeding easy to perform may combine with posterior turbinectomy disadvantage: 25% show no improvement Thomas, et al, 1985
Submucous Resection of Bone method: anterior incision over head of the inferior turbinate resection of the anterior 1/3 using curved scissors advantage: useful - uncontrolled perrenialenlarged inferior turbinate easy little bleeding or post-operative crusting or drainage preservesmucosa disadvantage: may require general anaesthesia need packing inferior long-term results to turbinectomy House P, 1951. Submucous Resection of the Inferior Turbinal Bone. Laryngoscope 61(7), 637 -648.
Soft Tissue. Cautery method(s): unipolar single - 3 points or bipolar cautery * advantage: simple equipment and simple to do disadvantage: difficult to determine degree of thermal injury, pain may bediffulcultto control by local anaesthesia mucosal loss with prolonged time for remucosalization ie. crusting and rhinorrhoea risk of sequestriumformation: persistent swelling fetor rhinorrhoea crusting * Hurd L, 1931. Bipolar electrode electrocoagulation the inferior fro of turbinate. Arch. Otol 13, 442
Steroid Injection: method: 0. 5 cc Kenolog( 40 mg/ml ) on spinal needle advantage: quick, under local anaesthetic, rapid results disadvantage: lasts 4 weeks facial flushing ( 5% ) at least 11 reports of blindness ( 1 at UC-Irvine ) small risk of septal perforation or sequestrium Mabry R, 1983. Corticosteroids otolaryngology: in intraturbinalinjection. Otolaryngol. Head and Neck. Surg 91(6), 717 -720
CO 2 Laser method: defocused and 10 W continuously to the anterior 1/3 of the inferior turbinate advantage: less bleeding, less pain, faster healing disadvantage: associated with synechiaeformation Selkin S, 1985. Laserturbinectomy an adjunct torhinoseptoplasty as. Arch Otolarygol 111, 446 -449
KTP Laser method: 532 nm laserscope 1 mm wide, 1 mm deep 8 W continuous X hatched and teflonsplints placed advantages: 85% improvement at 2 -4 year follow-up no packing and no bleeding disadvantages: specialized equipment 2 weeks ofrhinorhoea 8 weeks of crusting Levine. H, 1991. The potassiumtitanyl phospahte laser fro treatment of turbinate dysfunction. Otolaryngol. Head and Neck. Surg 104(2), 247 -251
Cryotherapy method: closed nitrous oxide cryo 'gun' at -40 c for 60 -75 seconds to 4 places on the sup & ant head of the inferior turbinate advantages: local anaesthesia no bleeding littledyscomfort may combine with neurectomyfor vasomotor rhinitis 85% improvement at 2 follow-up yr. disadvantages: until recently required specialized equipment rhinorrhoeaif do not combine with neuroectomy , inferior long-term results compared turbinectomy to * * Ozenberger. J , 1973. Cryotherapyfor the treatment of dhronic rhinitis. Laryngoscope 83, 508 -16
Turbinectomy methods: anterior 1/3 or total* advantage: * despite. Goode's criticisms in 1985 do not appear to cause atrophic rhinitis useful forhypertrophicposterior 'mulberry' turbinates best long term results disadvantage: most post-operative dyscomfort pain/crusting / usually requires packing 3 -5% significant bleeding and when combined with other nasal procedures under general anaesthesiait led to prolonged hospitalization. * * Elwany S and Harrison R, 1990. Inferior turbinectomy Comparison of four techniques. : Laryngol Otol 104, 206 -209 J Ophir, D 1992. Long-term follow-up of the effectiveness and safety of inferior turbinectomy. Plast Reconst Surg (6), 985 -987 90
Neurectomy methods: trans-nasal: Malcolmson 1959 , trans-antral: Golding -Wood, 1962 endoscopic El Shazly 1991 : , advantages: 90% improvement of rhinorrhoea disadvantages: possible reduction of maxillary sensation conjunctival irritation 'red eye' (25%) may regenerate in time El Shazly M, 1991. Endoscopic. Surgery of the. Vidian Nerve. Preliminary Report. Ann Otol Rhinol Laryngol 100: 536 -539.
Cryotherapy Neurectomy : method: apply probe 1 minute -180 C to the vidian nerve 6 mm posterior to the sphenopalatineforamen 1 cm posterior toposteriorborder to the middle turbinate or 1. 2 cm above & lateral to superior border of the choana advantages: quick can use in conjunction with -turbinate reductio cryo well tolerated on out-patient basis 86% improvement disadvantages: unpredictable extent of result operator experience dependent Strom M, 1989. A long-term assessment of cryotherpyfor testing vasomotor rhinitis. Ear Nose and Throat 69(12), 839 -842